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ATRIO Prime Rx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for ATRIO Prime Rx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on ATRIO Prime Rx (PPO) in 2026, please refer to our full plan details page.
ATRIO Prime Rx (PPO) is a PPO plan offered by ATRIO Health Plans available for enrollment in 2025 to people living in Douglas County. This plan received an overall rating of 2.5 out of 5 stars in 2026.
It's important to know that ATRIO Prime Rx (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about ATRIO Prime Rx (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For ATRIO Prime Rx (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $90.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $400.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6300.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6300.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The ATRIO Prime Rx (PPO) plan features an annual drug deductible of $400. Beneficiaries enjoy no copay for Tier 1 preferred generic and Tier 6 select care drugs for both 1-month and 3-month supplies at standard pharmacies and standard mail order. Tier 2 generic medications are also highly affordable, requiring an $8.00 copay for a 1-month supply and a $16.00 copay for a 3-month supply. For higher-tier medications, Tier 3 preferred brands require a $47.00 copay for a 1-month supply, and Tier 4 non-preferred drugs carry a $100.00 copay. Tier 5 specialty drugs require a 28% coinsurance for a 1-month supply at standard pharmacies. Standard mail order and standard pharmacy options are available for 3-month supplies of Tier 3 and Tier 4 drugs at double the 1-month copay rate.
Additional Benefits
The ATRIO Prime Rx (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, annual physicals, and home health services. For unexpected care, emergency room visits require a $140 copay, while inpatient hospital stays carry a $350 daily copay for the first several days with no coinsurance. Outpatient surgical and hospital services are also covered with fixed copays and no coinsurance, ensuring predictable out-of-pocket costs. This plan also includes valuable everyday benefits, including dental care with no copay up to a $350 quarterly limit and routine eye exams for a $15 copay. Prescription hearing aids and eyewear are both covered with no copay up to annual limits of $1,500 and $200, respectively. Additionally, members benefit from no copay for up to 12 one-way transportation trips and a $75 quarterly over-the-counter item allowance.
Inpatient Hospital See details
Inpatient hospital services are covered by ATRIO Prime Rx (PPO) with no coinsurance, requiring a $350 daily copay for days 1 through 8 for acute care and days 1 through 6 for psychiatric care, with no copay for remaining days. Prior authorization is required, and specific services such as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
ATRIO Prime Rx (PPO) outpatient services are covered with no coinsurance, featuring a $275 copay per stay for outpatient hospital and observation services, and a $225 copay for ambulatory surgical center services, both requiring prior authorization. Outpatient substance abuse sessions have a $35 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
ATRIO Prime Rx (PPO) covers partial hospitalization benefits with a $55.00 copay and no coinsurance. This coverage ensures affordable access to structured, intensive outpatient mental health services with predictable out-of-pocket costs.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by ATRIO Prime Rx (PPO), with medicare-covered ground and air ambulance services requiring a $295 copay and no coinsurance. Transportation services are partially covered with no copay or coinsurance for up to 12 one-way trips per year to plan-approved locations, though transportation to any health-related location is not covered.
Emergency Services See details
ATRIO Prime Rx (PPO) covers emergency services with a $140 copay and urgently needed services with a $65 copay, both featuring no coinsurance and copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent care are partially covered up to a $250,000 maximum with a $140 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Primary Care benefits under ATRIO Prime Rx (PPO) are partially covered, featuring primary care physician visits with no copay and no coinsurance, though podiatry and non-routine chiropractic services are not covered. Most other covered services, including specialists, therapy, and mental health sessions, require no coinsurance and copays ranging from $20 to $35.
Preventive Services See details
ATRIO Prime Rx (PPO) covers Medicare-covered preventive services, annual physical exams, kidney disease education, and other screenings with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance (prior authorization required) and include memory fitness, alternative therapies, and a personal emergency response system, while services such as health education, nutritional benefits, and in-home support are not covered.
Hearing Services See details
ATRIO Prime Rx (PPO) partially covers hearing services, offering routine exams for a $35 copay and no coinsurance, and prescription hearing aids with no copay, no coinsurance, and a $1,500 annual maximum. OTC hearing aids, along with inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by ATRIO Prime Rx (PPO), offering one routine eye exam per year for a $15 copay, no coinsurance, and no deductible, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 annual limit for contacts or complete eyeglasses, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
Dental services are covered by the ATRIO Prime Rx (PPO) plan, which offers Medicare-covered dental services for a $35 copay and no coinsurance. Other preventive and comprehensive dental services—including exams, cleanings, and surgical procedures—are covered with no copay and no coinsurance, up to a maximum benefit of $350 every three months for both in-network and out-of-network care.
Home Infusion bundled Services See details
ATRIO Prime Rx (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, have a coinsurance ranging from no coinsurance to 20%, with insulin drugs also carrying a $35 copay.
Dialysis Services See details
Dialysis Services are covered under the ATRIO Prime Rx (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by ATRIO Prime Rx (PPO), with durable medical equipment (DME), prosthetics, and medical supplies requiring prior authorization, no copay, and a 20% coinsurance. Diabetic equipment is partially covered with no copay and no coinsurance, though diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
ATRIO Prime Rx (PPO) diagnostic services are partially covered, excluding lab services, and feature no coinsurance alongside a $0 to $15 copay for diagnostic procedures and tests. Covered radiological services require prior authorization and range from no copay for diagnostic radiology to a 20% coinsurance for therapeutic radiology and a $15 copay for outpatient X-rays.
Home Health Services See details
Home Health Services are covered by the ATRIO Prime Rx (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by ATRIO Prime Rx (PPO) with no coinsurance and a $20 copay, though prior authorization is required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) care is covered by ATRIO Prime Rx (PPO) with no coinsurance, requiring a daily copay of $20 for days 1 through 20 and $175 for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard 100-day Medicare limit are not covered.
Other Services See details
ATRIO Prime Rx (PPO) provides coverage for several other services with no copay and no coinsurance, including unlimited acupuncture, annual wellness visits, and limited-duration meals after hospital stays or for chronic illness. Over-the-counter (OTC) items are also covered with no copay and no coinsurance up to $75 every three months, though nicotine replacement therapy and naloxone are not covered.
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